Central venous access - Stanford University



General considerations

• Central venous pressure monitoring, administration of pressors, inotropes, poor peripheral access, long-term anticipation of IV meds, hypertonic solution (TPN), HD (CVVH) or plasmapheresis, Swan-Ganz catheterization, transvenous temporary cardiac pacing.

• Contraindications. Controversial, technically there is no absolute contraindication to a central line. Consider vein thrombosis, coagulopathy, untreated sepsis.

• Scheduled, routine exchange catheters generally not indicated (see meta analysis published in Crit Care Med 1997;25:1417 shows no benefit).

• Subclavian lines have lowest risk of infection, though no head-to-head comparison of subclavian v. internal jugular (see JAMA 2001;286:700).

Technique

• Position patient supine and Trendelenburg (to engorge veins, maximize target, and minimize risk of air embolus).

• Use prep solution on stack of gauze pads to prep area wide using circular motion in to out on last pass. Anesthetize area with lidocaine (aspirate as you inject) including the periosteum in the case of subclavian line, which can be most sensitive. Drape sterile field wide, cover patient up as much as possible so you can place all of your equipment on the sterile field.

• Flush all lines using heparinized saline (contraindicated in patients with HIT) in blue sponge bowel and clamp off.

• Advance needle finder slowly, aspirate at all times, even when withdrawing. After flash of blood is seen in locator, draw back to ensure good flow and dark coloration. If arterial, remove and compress 5-10 minutes. If air is drawn back, then pneumothorax is likely if IJ/subclavian, will need stat chest x-ray, decompress if tension.

• Remove the syringe from locator and stabilize the needle with one hand. Feed the wire in (J-shaped end). If you meet any resistance, draw back wire and assess for adequate flow with syringe and re-attempt. If you induce any ectopy, this is may be a good sign that you are in the RA/RV, especially if LBBB pattern; just withdraw back into the SVC.

• Once wire is threaded, do not let go of the wire. Withdraw the needle, extend the puncture site with one stab of scalpel 1/3 buried. Then run catheter over wire (Seldinger technique), see below for position of catheter. Use syringe to pull back a tinge of venous blood and flush all ports. Clamp off all ports and place green caps on prior to sewing into skin with two simple stitches.

• Order stat chest X-ray to assess positioning, rule out pneumothorax, hemothorax

Subclavian vein

|Advantages |Disadvantages |

|Anatomy is more reproducible even in obese patients given bony landmarks |Highest risk of pneumothorax (1-8%). Left side is slightly higher than |

| |right due to higher dome of left pleura |

|Improved patient comfort; greater ease of dressing and maintenance |Not easily compressible site (can compress with two fingers though) |

|Lowest incidence of infection |Subclavian artery puncture/hemothorax risk 0.5-1% (supra1.2 g/dL suggestive of transudate (e.g. “diuresed effusions from CHF) (Am J Med 2001;110:681)

– Also consider cytology, cell count, glucose, pH, cytology, amylase, rheumatoid factor, ANA

• Tuberculosis, culture 25% sensitive, 100% specific; pleural biopsy 90% sensitive. Pleural effusions generally total protein >4 g/dL

• Malignancy, cytology and biopsy 68% sensitive, 100% specific

– Sensitivity for malignancy not dependently on volume; 10 cc of fluid appears adequate (Chest 2002;122:1913)

• Infection, no absolute WBC criteria can exclude infection

• If pH 7.0-7.2 or LDH>1000: do serial taps to assess need for chest tube.

Chest tube indications

• Sclerotherapy for malignant effusions or large recurrent effusions

• Complicated parapneumonic: pos gram stain, pH 250 PMN/(L and positive ascites culture diagnose SBP.

• Serum-ascites albumin gradient ( 1.1 g/dL indicates portal hypertension (cirrhosis, cardiac, massive liver metastases, hepatocellular CA, “mixed”); hip > shoulder > elbow.

• If sternoclavicular joint involved, consider IV drug use or pre-existing joint disease.

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Lateral approach

Anterior approach

Median approach

spinal needle is inserted usually between the 3rd and 4th lumbar vertebrae

Roderick Tung, M.D.

Position of catheter

• Catheters should terminate in distal inominate vein or proximal superior vena cava, 3-5 cm proximal to junction of SVC and right atrium.

• Right sided insertions, caval junction is about 13 to 16 cm from right-sided IJ or subclavian skin punctures

• Caval junction 15 to 20 cm from left-sided insertions

|WBC |Polys |Glucose | |Normal | ................
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